Guest Editorial

Flawed Regulations Keep IMGs on Sidelines in Pandemic

June 04, 2020 09:04 am Shyam Odeti, M.D., M.S.

Health care is in the middle of a crisis unprecedented in our lifetimes, with more than 6.3 million confirmed cases of COVID-19 and 383,000 COVID-related deaths around the world.(www.who.int) U.S. health care was overwhelmed with a steep rise in COVID-19 cases beginning in mid-March. Unequipped and shocked with a flood of sick patients, hospitals and other health care facilities could not keep up. Cities like New York and Boston became epicenters, and soon body bags begin to fill makeshift morgues. Clinics and hospitals ran out of personal protective equipment and physicians turned to social media with the hashtag #getmeppe in a plea to the nation. In the battle against an invisible enemy, these frontline cities needed resources from beyond their regions and ideas beyond the routine.

[headshot of Shyam Odeti, M.D., M.S.]

Shyam Odeti, M.D., M.S.

On March 17, the Trump administration expanded Medicare coverage of telemedicine services and relaxed requirements related to the Health Insurance Portability and Accountability Act. This allowed patients to access doctors using a wider range of communication tools, such as FaceTime and Skype. It also made it much easier for doctors and patients to connect through audio-only telehealth. Most states waived license requirements for telemedicine. Unfortunately, these actions were far from adequate in solving the crisis.

On April 2, this tweet from a physician friend in New York(twitter.com) caught my attention: "Healthcare friends: we are in dire need of your help in @NYCHealthSystem to connect w patients and families and in goals of care conversations #COVID19 Pandemic. We need any & all palliative care-minded clinician volunteers who can help remotely."

A day later, a physician from another large, New York-based health system told me that she, her husband and two kids were infected with COVID-19. About 60% of hospital staff known to her also had tested positive and there was no sign of patient inflow slowing down. Busy hospitals did not have enough internists or family physicians to manage all patients with COVID-19. Surgeons, dermatologists, ophthalmologists and other subspecialists were drafted into ER, ICU and medicine units to take care of these patients.

With a sense of helplessness in dealing with this stress day after day, she said: "I am worried that I may lose empathy toward patients."

These physicians were pleading for help from outside their regions, and so were numerous governors, health systems and the Federal Emergency Management Agency.

I could feel their anguish and wished I could help, but unfortunately, my visa restrictions tied my hands. Immigrant physicians practicing on H-1B work visas are authorized to work only under an employer who has filed an H-1B petition with U.S. Citizenship and Immigration Services. Applying for a new H-1B petition is a complex, multistep process that takes several months, and some employers may not be able sponsor an H-1B petition. These restrictions leave immigrant physicians who are willing to help unable to do so. Having trained in family medicine at East Tennessee State University and worked in a hospital for the past six years, taking care of sick patients and having goals-of-care conversations was my forte. I wanted to help, and so do many of the roughly 12,000 other U.S.-trained immigrant physicians(www.medpagetoday.com) who hold H-1B visas.

It takes decades for physicians from some countries to get the permanent resident card, or green card, that gives them flexibility to work without special authorization. A physician organization, Physicians for American Healthcare Access, recently assessed how many of these international physicians would be willing to volunteer to work in areas such as New York City during the pandemic if they were provided flexibility through a green card. Out of 256 responses to an online poll from physicians who are here on visas, 239 expressed willingness to help in some capacity, given the opportunity.

Current immigration laws prevent us from tapping into this sizeable, underutilized physician group during a national emergency. One potential solution is the bipartisan Healthcare Workforce Resilience Act. The AAFP recently sent letters to the House(2 page PDF) and Senate(2 page PDF) in support of the bill, which would reallocate 15,000 unused employment-based visas for doctors that were previously authorized by Congress. The bill also would provide expedited processing, which could potentially enable up to 15,000 physicians to receive the benefits and flexibility of a green card and enable them to work in areas of dire need immediately without visa hassles.

Immigrant physicians could make a difference in rural communities as well as big cities. More than three-fourths of rural U.S. counties are considered medically underserved due to physician shortages.(www.ncsl.org) A 2019 study in The New England Journal of Medicine showed that more than 50% of rural physicians were 50 or older, compared to only 39% of urban physicians.(www.nejm.org) Also in 2019, a national survey of fourth-year medical students(www.merritthawkins.com) showed that only 1% of respondents expressed interest in practicing in rural areas with less than 10,000 residents and just 2% in towns with a population less than 25,000.

Due to aging physicians and a decreased influx of younger physicians, the average number of rural physicians is just 12 per 10,000 people, compared to the national average of 27 per 10,000. According to the aforementioned New England Journal of Medicine article, rural health care is heading for an even greater crisis with the physician rate anticipated to sink to 9.4 doctors per 10,000 people by 2030.

International medical graduates have long played a significant role in bridging this gap in rural health care. IMGs, who represent one-fourth of the U.S. physician workforce,(jaoa.org) are twice as likely to practice primary care -- 62%, compared to U.S. graduates at 31%(www.ama-assn.org) -- and are more likely to practice in rural and underserved areas.(depts.washington.edu) Research also has shown that patients treated by IMGs have a 5% lower 30-day mortality rate.(www.bmj.com)  

Resident physicians from other countries practicing in the United States on J-1 visa waivers are required to return to their home country for two years after completing their training before they can apply for another visa or a green card. The Conrad 30 program, however, allows up to 30 physicians in each state to remain in the United States without returning home if they agree to practice in underserved areas for three years.

Unfortunately, with no incentive for working extended time in rural areas, physicians tend to relocate after those required three years in pursuit of other opportunities -- like research -- and the quest for an expedited path to a green card. They want stability for their families and the ability to travel outside the country.

I recently conducted a survey and found that 90 of 152 physician respondents (59%) who had completed their three-year J-1 waiver obligation moved from their original underserved work site. In a similar study published in 2010,(www.ncbi.nlm.nih.gov) 35 of 47 immigrant physicians (74%) who served in rural areas of Washington state moved toward more urban areas after leaving J-1 waiver employers.

Retention of these physicians is just as important as recruitment. One solution is to incentivize these physicians with expedited green cards if they serve five years. In my survey, 92% of these physicians expressed willingness to stay in their communities if they could get a green card at the end of five years. Other research has shown(www.ncbi.nlm.nih.gov) that once physicians remain in a community for five years, they are much more likely to stay.

Bills have been introduced in both the House(www.congress.gov) and Senate(www.congress.gov) calling for reauthorization of the Conrad 30 J-1 visa waiver program, which would be a step toward that goal of long-term retention. In its recent letters to Congress, the AAFP expressed support for reauthorizing and improving that program.

With thousands of health care workers already infected with COVID-19 in the United States, it's likely that many of the roughly 12,000 international physicians working on visas will get sick. Unfortunately, there is no protection offered to their families if any of these frontline physicians die while fearlessly fighting this battle to protect American communities. Their dependent families would be deported under current laws, and this keeps them awake at night. And H-1B work visas require renewal every two to three years, which poses significant challenges in international traveling to visit family and adds stress due to uncertainty.

These heroes and their families must be protected. Serving rural communities by steering them through health care crises requires a long-lasting solution, and frontline immigrant physicians are a critical part of it.

It's time to bring an end to the worries associated with their immigration status so they can focus on treating their patients.

Shyam Odeti M.D., M.S., is a hospitalist in Johnson City, Tenn.